How Barrio Adentro Wrecked Venezuela’s Health System

It’s been twenty years since Hugo Chávez won his first election, and fifteen since one of his government’s banners was launched, Barrio Adentro, the first of many social programs (misiones) that helped build his popularity. The program, initially praised for its focus on primary care and accessibility, wound up compounding the current health crisis: not only did it fail to address the problems it was designed to solve, it also channeled investment away from the parts of the system that did, sorta, work: the hospital network.

Today, long forgotten infectious diseases are back in Venezuela, more than ten years after Cuban doctors first came “to lend us a hand.”

Barrio Adentro can be traced back as far as 1999, when a group of Cuban doctors was brought to Venezuela following that year’s catastrophic landslides in Vargas State, which killed tens of thousands. A year later, Chávez signed the first cooperation agreement with Cuba. In 2002, a series of strikes were called by the Venezuelan Medical Federation, demanding the payment of a $100 million-debt the Ministry of Health held with the medical guild. Chávez, true to his soul, ignored that, and instead started negotiations with Cuba for more doctors.

By May, 2003, some 150 Cuban doctors had been deployed in Caracas. That December, Chávez made the Barrio Adentro Mission official, and expanded it to the whole country. After that he added the first group of Venezuelan integral doctors, later known as Integral Community Doctors (MIC, for its Spanish acronym).

Had Barrio Adentro remained a primary care program, it may have been a valuable complement to the existing ambulatory network, whose reform had been under discussion since the late 80s, at least. But the program quickly encompassed more and more curative functions traditionally limited to the Venezuelan hospital network. By 2005, the government announced Barrio Adentro 2, an expansion based on the construction of 600 Centers of Integral Diagnosis (CDIs), rehabilitation rooms and 35 high-technology centers that would supposedly provide CAT and MRI scans to the population for free.

Not only did it fail to address the problems it was designed to solve, it also channeled investment away from the parts of the system that did.

By the time Barrio Adentro 3 started, meant for studying the condition of the current hospital network and developing a modernization plan, the program was a massive source of corruption. Even though millions of dollars were invested, all hospitalary interventions, from surgeries to laboratory tests where reduced in about 75%, between 2005 and 2011. In 2006, after the Caracas Cardiology Hospital was inaugurated, the government announced a further expansion, Barrio Adentro 4, aimed at building another 15 highly specialized hospitals throughout the country, none of which has been finished as of 2018.

All of these expansions meant a staggering amount of money was invested. The exact figures are virtually impossible to find, but according to estimates from NGO Transparencia Venezuela, at least$29,7 billion were spent between 2005 and 2014. The vast majority of this money came from PDVSA, representing 51,3% of the money spent in all social programs until 2014, and more than thrice the value of Venezuela’s international reserves, as of June 2018.

But this huge investment hasn’t been reflected in the quality of Venezuela’s healthcare. According to official sources, 609,704,922 medical consultations had been reported by the Barrio Adentro program until 2014, numbers that to many have been greatly exaggerated. The Universidad Católica Andrés Bello’s ENCOVI 2017 poll suggests that some 200,000 patients benefited from Barrio Adentro that year, a sharp contrast with the more than 118 million consultations reported by the government. For this number to match, each patient should’ve consulted around 600 times in 2017.

The ENCOVI data matches with off the record reports that claim that over 80% of the 13,496 popular clinics acknowledged by the government in 2017 were closed. The remaining centers would be managed by some of the 14,000 MICs, with some reports saying that only 1,094 of the 30,000 Cuban doctors in Barrio Adentro remain in Venezuela, as of 2017.

The Cuban medical mission managed popular clinics and CDIs for years, independent from the Health Ministry, which made it impossible to coordinate actions inside the health system.

But beyond these assumptions, Barrio Adentro’s failure is unequivocally reflected in the evolution of sanitary indicators in Venezuela, as presented in this report from Transparencia Venezuela. Family planning, one of the key areas where primary care programs are expected to act, is non-existent: between 2010 and 2015, Venezuela presented the highest teenage pregnancy rate in South America. According to the last available data from the Health Ministry, 756 maternal deaths were registered in 2016, compared to 346 in 2010. The maternal mortality rate is estimated to be around 110 maternal deaths per/100,000 registered newborns, a number not seen since the late 50s and almost twice as that registered throughout the 90s and early 00s. Child mortality, another key indicator of human development, increased 92% compared to 2010, with an estimated rate of 19 deaths per 1,000 registered newborns.

Another key activity, vaccination, also had a sharp reduction since Barrio Adentro came about. Coverage with the vaccine against poliomyelitis fell from 86% in 2000 to 58% in 2008. On the other hand, after an initial increase between 2004 and 2006, coverage against diphtheria, whooping cough and tetanus, fell to just 22% in 2008. Nine years later, we saw the consequences.

The hospital network today must cover more patients than before, with an extremely damaged and outdated infrastructure. The Cuban medical mission managed popular clinics and CDIs for years, independent from the Health Ministry, which made it impossible to coordinate actions inside the health system, rendering epidemiologic vigilance networks useless, and paving the way for the re-emergence of long-eradicated infectious diseases.

But the program did work to bolster the government’s interests. Chávez sold Barrio Adentro to both Venezuelans and foreigners, as proof of his interest in the people’s welfare, and it was key for his victory in the 2004 referendum. Even today, a quick search in Google Scholar will show hundreds of papers, from Venezuela and abroad, analysing Barrio Adentro’s role as a “tool to fight exclusion and strengthen democracy”.

It was also the project that cemented the relationship between Venezuela and Cuba, paving the way for the pervasive penetration of the Cuban government into the Venezuelan State.

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As of 2010, Venezuela paid Cuba approximately $11,317 per month on average for each professional it provided.18 By contrast, Cuban doctors reportedly receive $425 per month, although this is more than double what they received six years ago and similar to what they earn on medical missions to Brazil.19 Cuban doctors would be earning only up to $64 a month back home.20 It is clear that these services are both a major item in the Cuban-Venezuelan trade balance, as well as a significant source of revenue for the Cuban government and for Cuban workers abroad.

There’s also the fact that many Barrio Adentro CDI’s are massively incompetent at what they do. Anyone in the medical field can attest to this. You’d have to be crazy to write a reference to a CDI, at least where I did my ‘rural’.

The gold standards for measuring public health systems are Life Expectancy and Infant Mortality. It was evident ten years ago that compared to the rest of Latin America, post-1998 Venezuela was below average in improving either Life Expectancy or Infant Mortality. That indicated- to me at least- that Barrio Adentro wasn’t the roaring success it was supposed to be.

No like button for the article, so here it is: Really good in-depth analysis and exposure! It is this sort of factual well-researched article that keeps me coming back to this website.

I’m still wishing someone would do an analysis of the agricultural / animal husbandry industries in Venezuela. All I’ve seen elsewhere are bits and pieces about 30% capacity on poultry operations, severe pollution problems for fishermen in the Lake Maracaibo region, cattle being stolen and slaughtered, ranches being expropriated. Nothing in terms of a comprehensive overview, other than the bit that Venezuela imports 70% of its food. The little research I tried is simply that Venezuela used to export food, and once had over 600,000 head of cattle in Bolivar (then a British-owned ranch was “expropriated” and Venezuela ended up paying $11,000,000 in compensation). Given the current degraded economic level, it seems to me that importing food with oil, if oil production were reestablished, would not be good, but just reestablishing food production to 100% would be significant. Expanding it beyond that would be a priority – in my view. Someone please write something about Venezuela’s most advantageous crops / husbandry, arable / grazable land and fishing grounds, or whatever is necessary to give an idea of what has happened in those sectors.

The Boletín Epidemiológico 52 2016 reported Infant Mortality in 2016 to be 11,466 deaths, an increase of 31.12% from 2015’s 8,812 deaths. Caracas Chronicle and other news sources reported this in May 2017. Several days later, the Health Minister was fired. In Chavezuela, telling the truth can make you job-free.

The World Bank gets its data from governments. As of the August 2018 update, the World Bank listed Infant Mortality in Venezuela as being 8,400 deaths in 2016 which indicates to me that the GOV sent false data to the World Bank. Recall that for 2016, the Boletín Epidemiológico- a GOV source- listed 11,466 infant deaths (published May 2017).

The World Bank update the following month for September 2018 has different data. Did the World Bank get this from the GOV? Is the GOV ‘fessing up and delivering correct data?World Bank: Number of infant deaths in Venezuela: September 2018 data
2010 8599
2011 8603
2012 8787
2013 9272
2014 10155
2015 11520
2016 13335
2017 15345

This is actually very interesting. The September update is similar to that reported in the bulletin. I can’t tell if the government corrected the data willingly, but at least those numbers suggest that statistics are still being recorded somewhere… just hidden away from the Venezuelan public opinion.

My understanding is that some conditions, Dr. Gabaldon is not allowed to diagnose and recommend a treatment for over the internet. That does not prevent you from seeking out an “action plan” elsewhere.

Instead of lambasting Dr. Gagaldon for his lack of a solution, why not offer your own – specifically – sans silly suggestion like military intervention. While that might work, it would put the US on the hook for the clean up, and that’s bad business for a man like Donald Trump.

Just a couple of other observations, in seriousness, for the author. I’ve never been a supporter of Chavez but I did see a presentation many many years ago in Toronto put on by some of the architects of the Barrio Adentro program, and I did not doubt their sincerity and their expertise in public health. They did not strike me as ideologues. They struck me as professionals who saw an opportunity to construct a solution to a very large problem, and a government with the will to fund it. Also, it seemed to me that at least in its initial and general form, the program had some potential merit, in theory, although the government was sure to screw it up for lack of an ability to manage, and due to the inevitable corruption and political interference.

The problem of how to provide access to good, primary care treatment to vastly underserviced (i.e. poor) areas in Venezuela continues to exist. Barrio Adentro – for the reasons you describe very well- never did that, though it offered the promise of that, and it then expanded in scope to overtake the public hospital system which had basically been fairly functional (people say). Also, it seems to me, having used the Venezuelan private health system myself (in various and sundry health emergencies easily addressed by rounds of antibiotics or a few bags of intravenous drip solution), that there is an over-reliance in the private system on expensive specialists that must also drive up the cost of private care for middle class folks (and the companies and institutions -including government institutions, interestingly- that provide them with private insurance).

So for the future, how do you get competent, Venezuelan doctors into those underserviced areas, to provide primary care? If they were paid adequately and provided some security and the right tools, would this not be fairly straight forward, and a good and necessary thing? In Canada, we pay doctors a premium to work in the North or rural areas. We provide attractive incentives for doctors from other countries (i.e. South Africa, for some reason) to come and work in these areas. Is it not basically as simple as that?

@Cancklehead: Now I see. Canada, you’re definitely socialist. You supported Chavez. You only do things that feel good. Example: the mess created by Mr. Trudeau carbon tax. Your Trudeau is a mini Chavez who can not control the provinces. The Big Government is not the solution in Venezuela. Let the people live and die naturally, why do we all have to live until 90 yrs old? Why is that the government responsibility? BTW, the health system of the northern Canadian vast areas is not the best example. Those people always lived there until God took care of business. I guess you also want to bring the same to Yamomani Indians in Amazone.

@cabucklehad: it doesn’t matter. I’m not God to judge. The end of days will be identical to all. I hope it will be harder to socialists, theccorrupted and the liars. I’m a sinner too but of another kind. God bless you. I’ll go away for a while.

As I said, had Barrio Adentro limited to its original primary care attributions, it may have been useful. Nonetheless I doubt that neither Chávez, nor the Cuban regime ever wanted that. For years, Venezuela covered the needs of small towns with a figure called “rural doctors”. After venezuelan doctors graduate, if we want to work at a Venezuelan hospital or take a postgraduate course in a Venezuelan University, we must comply with the Article 8 of the medical practice law, which mandates either one year of work at a rural location, or two years at a major hospital’s emergency services. Until some 10-15 years ago a rural doctor earned about 1000$ monthly, not a great wage, but one that covered most of your basic needs. As the crisis worsened it all went to hell, right now a rural doctor earns little more than 10$ per month. Since most of doctors now want to leave the country as fast as they can, only a few do the rural service, more because they want something to do while the papers they need to work abroad are ready.

If we expect to give rural locations and poor communities sustainable quality health care, the first step is to start working to stop the economic nonsense. After that, rural doctos should be offered better wages and benefits than those working in cities, since that’s the only way to get them to work away from their homes. In a post I wrote a few months ago I also suggested that after a thorough reform, the MIC program could tackle most of the problems in rural, low-income communities, since that was actually its original raison d’etre.

“Fail to address the problems it was designed to solve”. Not true, it succeded spectacularly at what it was designed for: propaganda and funneling cash to Fidel. Does anybody actually thinks it was designed to solve healthcare? Seriously?

“A year later, Chávez signed the first cooperation agreement with Cuba. In 2002, a series of strikes were called by the Venezuelan Medical Federation, demanding the payment of a $100 million-debt the Ministry of Health held with the medical guild. Chávez, true to his soul, ignored that, and instead started negotiations with Cuba for more doctors.”

Doctors take an oath to “do no harm”. They don’t take an oath to work against their best interests.

I’m not at liberty to give details (mostly because I don’t know the specifics), but a healthcare concern here in the states decided they were going to hire “anesthesia assistants” (a career invented by anesthesiologists) to supplement nurse anesthetists at their practice. Both are mid-level providers, but AA’s work under anesthesiologists only, whereas CRNA’s don’t have that professional limitation. The can actually compete against anesthesiologists. The anesthesiologists brought in a couple of AA’s and the entire department of CRNA’s walked out. Leaving only the two AA’s and a dozen MD’s to do the work of 30 CRNA’s. The result was catastrophic… for the anesthesiologists. The surgeons are the rainmakers, and their anesthesia counterparts threw them under the bus. NOBODY comes to get excellent anesthesia… they are the people behind the curtain. (literally) To make a long story short, the hospital fired the remaining anesthesia department and rehired all of the CRNA’s as a group practice.

The point being, if the physicians in Venezuela wanted to take industrial action, they could have. And they can now. But they don’t. Because the people have bought the lie that all must sacrifice for Chavismo.

Maybe Docteur Gabaldon should distinguish between doing something because it feels good than doing something that is good. The discussion overall is about feeling good but not concrete ways of doing the necessary good, even if some don’t survive along the way. It’s toug call.

Are you a relative to Dr Gabaldon the one who exterminated malaria born mosquitoes?

He used DDT, but socialists in the form of Greenpeace killed DDT because mosquitoes were more important than human and it makes them feel good.

Pepe: I don’t recall ever seeing a “Save the Mosquito” bumper sticker. But I do recall my youth and rarely seeing a Bald or Golden eagle. Today I can drive through the river valleys of southeastern Minnesota and see thousands of wonderful eagles due to the elimination of DDT. But you do have a point regarding the poor mosquito if it has been eradicated in Texas. Check with your local Catholic Charities and they perhaps could arrange shipment of a couple quadrillion of the cute, cuddly little critters to your door step.

@ASA58; sorry if you don’t see my point. We are not in Minnesota or Texas or Alberta. The point in discussion is Venezuela. And I’m talking erradicatiion of Malaria in Venezuela by the Armando Gabaldon.
Moron, near El Palito. Did that sounds familiar to you? DDT May have been bad for you but not for Venezuela – capeesh?

Two things about bario adentro, It’s yet another way for the Cuban dictatorship to send slaves abroad and collect hard currency. Secondly I myself had a horrible experience when I accompanied an older family member of my wife years ago to one of those Cuban slaves. That “doctor” had only 2 medicines in his cupboard and whatever the patient had those 2 medicines was all he could give. I’ll never forget the discussion I had with him, we both agreed that his service was inadequate to put it mildly. Socialism kills people always everywhere!!!!